Gap in the syllabus: Public health and policy

In the latest instalment of our series on LGBTQ+ inclusivity, Ilia Hionidou interviews Dr Forssell, founder of the LGBT Health Policy program at the George Washington University.

Earlier this year, the UK experienced a wave of protests against same-sex education in primary schools. Ilia Hionidou interviews academics about their experiences in teaching courses that feature LGBTQ+ content. The series discusses the benefits and backlashes of including LGBTQ+ studies in higher education across the UK and the US and aims to inform readers about important moments in LGBTQ+ history.

In 1897, Doctor Henry Havelock Ellis and literary critic John Addington Symonds published a medical monograph entitled Sexual Inversion; its thesis, founded on five years of accumulated data from studies, concluded that “sexual inverts” were as “natural” and biologically sound as those who engage in opposite-sex relations. This study acted as a springboard from which the modern concept of homosexuality would later emerge.

While the publication was sympathetic to “sexual inverts” and their struggles, Havelock Ellis and Symonds placed homosexuality and “sexology” firmly in the field of health practice and medicine. As gender and sexual minority movements have evolved, so have the approaches of medical and health experts in their treatment LGBTQ+ people.

Concurrent with the Obama administration’s politically “evolved” rationale regarding the LGBTQ+ population, Dr Forssell rolled the dice to successfully found the first program of its kind that trains current and future healthcare leaders to cultivate and enforce the most effective practices, policies, and strategies for handling LGBTQ+ health issues.

Dr Forssell founded the program based on a specific fundamental framework: it needed to be practical, interdisciplinary and internationally accessible. Firstly, the program’s structure should not aim to further research LGBTQ+ health inequalities, Forssell argues, but instead, it should put pre-existing research about LGBTQ+ health into practice. “The course is explicitly applied. We know of these health disparities: so how do we get rid of them? We know that the quality of care for LGBTQ+ people is not there and that it is culturally incompetent: so how do we increase competence?”

Secondly, the program adopts an interdisciplinary approach to the application of LGBTQ+ health: “Our program includes students who work in applied care, social work and medicine. We also have students that are mental health providers, clinical psychologists and policy drafters. There are at least three different schools within the university where all these subjects would fit, some of which would be the School of Public Health, the School of Medicine and Health Sciences, the School of Nursing, the School of Public Policy and Public Administration.” Dr Forssell stresses that policy is an integral part of the course as “the implementation of both large – and small – scale policy changes is crucially effective in altering practice”. On one hand, the program considers policy at the governmental, federal and state levels. On the other hand, it covers policies that are internally implemented within certain organisations and institutions. For example, at a clinical practice, do the intake forms address the gender and sexual diversity of their patients? Is the training protocol for front line staff inclusive of LGBTQ+ issues? Are the security and caretaking employees culturally capable of interacting with LGBTQ+ people?

Thirdly, Dr Forssell observes that because of the District’s liberal nature, “you preach to the choir if your only audience is in Washington D.C.”. It was necessary that the program would be accessible to people outside of the immediate D.C. area. Due to this, the majority of the program’s teaching is conducted online, and students also participate in two short residencies that take place annually over January and July. The format of the course makes it available to international applicants who want to study LGBTQ+ health from outside the US: “In its first year [the program] was just national, but in its second year we went international. [It] got a lot of attention and we started to receive applications from all over the world.”

Why, therefore, is it important to study LGBTQ+ health? Dr Forssell stresses that it must be studied, researched and included in higher education because “we know that members of the LGBTQ+ community are at a higher [health] risk. These health disparities exist, and they are real.” While LGBTQ+ health is commonly associated with the HIV/AIDS epidemic thatdisproportionately affects the LGBTQ+ community Dr Forssell believes that teaching about LGBTQ+ health in higher education nurtures the understanding that this goes above and beyond HIV/AIDS alone.

Dr Forssell spotlights the Minority Stress Model, a theory developed by I. H. Meyer, which indicates that when all extraneous variables are controlled, there is a mental and physical cost to being a member of a minority population that constantly has to be on guard as a function of discrimination and harassment. Dr Forssell outlines some of the immediate consequences observed by the Minority Stress Model: “we know [discrimination] has a direct effect on the immune system. We know it has a direct effect on socialisation. We know it has a direct effect on family relationships. All of those things contribute to and can potentially hurt a person’s health.” Furthermore, the Minority Stress Model applies not only to the LGBTQ+ community, but to any minority, or marginalised population. Dr Forssell illustrates that “a black woman who is well educated, lives in a great neighbourhood and has everything going for her – she experiences stressors that other people don’t, strictly due to her race.”

The LGBTQ+ population and health/medical services have a historically fraught and complex relationship. In June 2019, New York City celebrated the 50th anniversary of the Stonewall Uprising, a series of riots that took place in 1969, commemorated as the spark that ignited the modern Gay Civil Rights Movement in the US. With this newfound sense of resistance, homophile groups (such as the Gay Liberation Front, the Gay Activists Alliance, the Daughters of Bilitis and the Mattachine Society) used the momentum from Stonewall to fight against the wide-spread stigmatisation of and discrimination against LGBTQ+ people by targeting the American Psychological Association (APA), who, since the 1950s, had listed homosexuality as a psychological disorder in their Diagnostic and Statistical Manual of Mental Disorders (DSM).

As a direct result of the Stonewall Uprising, one of the first major campaigns of gay activists and homophile groups was to pressure the APA to remove homosexuality from theDSM list of psychological disorders. This classification cultivated a further intolerance against LGBTQ+ people and allowed health professionals to label same-sex relationships as abnormal, pathological and deviant. Treatment of this so-called “psychiatric disorder” included electric shock therapy and lobotomy.

In 1970 – the same year as the first Pride Parade in NYC and the first anniversary of the Stonewall Uprising – prominent gay activists Barbara Gittings and Frank Kameny demonstrated at the annual APA meeting. In 1972, the APA was persuaded to host a debate at their Annual Meeting called Psychiatry: Friend or Foe to the Homosexual?; A Dialogue featuring both Gittings and Kameny. On 15 December 1973, the APA passed the proposal led by the Nomenclature Committee and presented by therapist, activist, and author Charles Silverstein that requested homosexuality to be withdrawn from the DSM. Frank Kameny described this as the day “[homosexuals] were cured en masse by psychiatrists”.

Since then, Charles Silverstein was consistently involved in advancing inclusivity and research of the LGBTQ+ population in psychiatry and health studies as a Fellow for the APA. He has received numerous accolades from the APA that accredit the importance of his works which platform LGBTQ+ mental health. As well as being a member of the New York State Psychological Association’s (NYSPA) committee on Ethical Practices and for the APA’s Society for the Psychological Study of Gay, Bisexual, and Transgender Issues, Silverstein is the founder of the academic Journal of Homosexuality. In July 2019, Charles Silverstein attended theLGBT Health Policy and Practice Program Health Forum at the George Washington University totalk to the students about the impact of the Stonewall Uprising on LGBTQ+ health.

Dr Forssell describes the positive practical impact that some of his LGBTQ+ Health Program Graduates have had on non-academic communities: “One example was a student who was in the field of education as a public high school teacher in D.C. He lobbied for and got the District of Columbia to change the Sexual Health curriculum which is now written to be more LGBTQ+ inclusive.” Dr Forssell explained that it had been a long time since anybody had attempted to lobby the school board for this alteration: “He provided content, the school board approved, and it is now being taught. This is currently having an impact on kids from Kindergarten through to 12th Grade.” Dr Forssell also mentions a student with a background in social work who was working at a mental health facility in Western Maryland: “She has since risen up and the clinic she works at is very on board. They are providing much better care to the LGBTQ+ population out in a part of the country that it is really needed. Western Maryland is quite rural and can be culturally oppressive to a sexual or gender minority person.”

LGBTQ+ Health Policy is being welcomed into open and tolerant higher education spaces with increasing acceptance. However, the provisions in response to the health needs of LGBTQ+ people are far from adequate: many healthcare systems across the world are ill-equipped to deal with transgender health, and do not satisfy the World Professional Association for Transgender Health’s “Standards of Care” while others simply refuse to treat gay-identifying patients. With such holes in governmental health policy, it is crucial that universities fill this gap so as to address, teach and implement appropriate policies that protect the health of their LGBTQ+ populations.